Thank you for your question
You submitted a single photo and you are 7 months out after having Restylane injections
in the tear trough area.
And you describe a situation where there is some lumpiness occurring after the procedure
and that resolved.
And now you feel like you're becoming more and more aware of the lumpiness in the under
eye area.
And you're concerned about having to go back for another injection at 7 months because
that's the timing you were recommended to come back for.
And you want to know how you can avoid lumpiness moving forward and whether this was a technique
issue by your doctor.
Well, I can certainly share with you some basic principles that apply to this particular
area and understanding that without a physical examination as well as not looking at any
photos beforehand, I can just give you a general idea on some of very important concepts that
would probably be helpful for you when you see your doctor.
A little bit of background, I'm a Board-certified cosmetic surgeon and Fellowship-trained oculofacial
plastic and reconstructive surgeon.
I have been in practice in Manhattan and Long Island for over 20 years.
And helping people with the under eye cheek area is a significant focus in my practice.
Use of injectable fillers as well as helping people with complications of injectable fillers
is a routine in my practice.
So I would begin by just giving you my impression when I see your photo.
When I look at the photo of the area that would be described as the tear trough as well
as an area just below the rim or the bone of the eye socket, the orbital rim, I see
what appears to be relatively prominent areas of filler.
Now, when we look at this photo, depending on what the lighting condition at the time
of the photo, it's almost like I can see what is referred to commonly as Tyndall effect
or bluish hue of filler when it is placed under the skin.
Now there is a variety of reasons for this and one of the things that I would be concerned
about and have you discuss with your doctor is about the amount of swelling that the hyaluronic
acid filler creates as a function of the nature of the material.
You see, when you place a hyaluronic acid filler like Restylane in any area, a certain
amount of water gets absorbed.
And depending of course on the level placed, that bluish hue, Tyndall effect, can be relatively
apparent.
It's not just the level.
It also has to do with the tissue.
When I look at your photo, my impression is that you have very light skin and your skin
is relatively thin and that you are relatively lean so there isn't much subcutaneous fat
or cushion between the filler and the skin.
And therefore, I think that this is an opportunity to actually discuss with your doctor different
strategies where it could be possible to reduce some of this material because one thing that
I would just mention as a variable is that when it comes to injectable fillers around
the eyes, even a material like Restylane is well-known to have, specifically Restylane-L,
will have a longevity of about 6 months when it's placed in the lips.
When the material is placed around the eyes, it can last considerably longer.
We've had patients where it lasted for years.
I think the general accepted theory or hypothesis is that the body forms a bit of a capsule
around the material and the material just doesn't get broken down as quickly.
Now that being said, the idea of course is when you look at the eye area and to improve
hollows, you want to restore up to a natural contour and you also want to maintain a transition
between the eye and the cheek that looks natural.
So there may be an opportunity here to also think about volume correction of the cheek
area.
Many times when patients come to me and present with under eye hollows, when I take their
pictures and I show them on the screen that they have not only under eye hollows but they
also have hollow cheeks that the filler effectively, if it's placed only in the under eye hollow
area, is kind of on a ledge and it's kind of sitting all by itself and it can make it
look more obvious.
When you place it artfully in a very smooth way with a transition between the cheek and
the eyelid, well the volume in the cheek and the transition into the under eye area is
much more natural.
So when I talk about cheek volume, I often discuss a concept called Structural Volumizing.
In Structural Volumizing, we're placing a material like Juvederm Ultra Plus or Juvederm
Voluma which I prefer because of the longevity of these materials, I place it into the bone
level, on the cheekbone as well as in the soft tissue in front of the cheekbone, in
the under eye area or referred to as the submalar area.
You can actually get this very pleasing natural balance between the two areas.
So I think that when you are seeing your doctor, of course, mention these concerns.
And of course, what I do routinely in my practice when I see my patients is I always look at
their before pictures.
I look at how they look after I have done a procedure such as this and we always study
opportunities to improve and maximize outcomes so that we can get the best results that makes
the whole face look better.
And so I think that these principles, the longevity of the filler, the placement of
the fillers and the possible additional benefits of fillers in other areas is very important
for you to discuss.
Not to mention that if an area does look overcorrected, that material can be dissolved using an enzyme
called hyaluronidase.
And so sometimes when patients come to me who have had filler done elsewhere, they'll
come to me and if they look like their overcorrected or just doesn't look right to me, I'll
start by saying let's just dissolve what you have and start fresh.
Or sometimes, we try to dissolve a little bit and see what happens.
It just depends on the individual case.
So I hope that was helpful, I wish you the best of luck and thank you for your question.
I have always been very skeptical about intruding on others privacy, loved ones or colleagues. However we all know curiosity can get the best of us at times and only by knowing the truth on some hot-button issues do we truly find peace and closure.
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